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TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care

Mirarchi, Ferdinando L. DO, FACEP*; Cooney, Timothy E. MS*; Venkat, Arvind MD, FACEP; Wang, David MD; Pope, Thaddeus M. JD, PhD§; Fant, Abra L. MD; Terman, Stanley A. PhD, MD; Klauer, Kevin M. DO, EJD, FACEP**; Williams-Murphy, Monica MD††; Gisondi, Michael A. MD; Clemency, Brian DO, MBA, FACEP‡‡; Doshi, Ankur A. MD§§; Siegel, Mari MD∥∥; Kraemer, Mary S. MD∥∥; Aberger, Kate MD, FACEP¶¶; Harman, Stephanie MD; Ahuja, Neera MD; Carlson, Jestin N. MD***; Milliron, Melody L. DO***; Hart, Kristopher K. DO, FACOEP†††; Gilbertson, Chelsey D. DO†††; Wilson, Jason W. MD, MA, FAAEM‡‡‡; Mueller, Larissa MD‡‡‡; Brown, Lori MD‡‡‡; Gordon, Bradley D. MD§§§

doi: 10.1097/PTS.0000000000000357
Original Articles

Objective: End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus.

Methods: We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes.

Results: Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%–78% noted “DNR”). Two of 9 scenarios attained consensus for code status (97%–98% responses) and treatment decisions (96%–99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs.

Conclusions: For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.

From the *UPMC Hamot, Erie, Pennsylvania; †Allegheny General Hospital/Allegheny Health Network, Pittsburgh, Pennsylvania; ‡Stanford University School of Medicine, Stanford, California; §University of Minnesota Center for Bioethics, Mitchell Hamline School of Law, Minneapolis, Minnesota; ∥Northwestern University Feinberg School of Medicine, Chicago, Illinois; ¶Caring Advocates, Carlsbad, California; **Michigan State University College of Osteopathic Medicine, Knoxville, Tennessee; ††University of Alabama at Birmingham Huntsville Campus and Huntsville Hospital, Birmingham, Alabama; ‡‡State University of New York at Buffalo, Buffalo, New York; §§University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; ∥∥Temple University School of Medicine, Philadelphia, Pennsylvania; ¶¶St. Joseph's Regional Medical Center, New York Medical College, Paterson, New Jersey; ***Saint Vincent Health System/Allegheny Health Network, Erie, Pennsylvania; †††INTEGRIS Southwest Medical Center, Oklahoma State University Center for Health Sciences, Oklahoma City, Oklahoma; ‡‡‡University of South Florida, Tampa, Florida; and §§§University of Minnesota Medical School, Minneapolis, Minnesota.

Correspondence: Ferdinando L. Mirarchi, DO, FACEP, Department of Emergency Medicine, UPMC Hamot, 201 State St, Erie, PA 16550 (e-mail:

The authors disclose no conflict of interest.

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